The final project for this course is the creation of a white paper. Much of what happens in healthcare is about understanding the expectations of the many departments and personnel within the organization. Reimbursement drives the financial operations of healthcare organizations; each department affects the reimbursement process regarding timelines and the amount of money put into and taken out of the system. However, if departments do not follow the guidelines put into place or do not capture the necessary information, it can be detrimental to the reimbursement system. An important role for patient financial services (PFS) personnel is to monitor the reimbursement process, analyze the reimbursement process, and suggest changes to help maximize the reimbursement. One way to make this process more efficient is by ensuring that the various departments and personnel are exposed to the necessary knowledge. For your final project, you will assume the role of a supervisor within a PFS department and develop a white paper in which the necessary healthcare reimbursement knowledge is outlined. The project is divided into two milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These milestones will be submitted in Modules Three and Five. In this assignment, you will demonstrate your mastery of the following course outcomes: • HCM-345-01: Analyze the impacts of various healthcare departments and their interrelationships on the revenue cycle • HCM-345-02: Compare third-party payer policies through analysis of reimbursement guidelines for achieving timely and maximum reimbursements • HCM-345-03: Analyze organizational strategies for negotiating healthcare contracts with managed care organizations • HCM-345-04: Critique legal and ethical standards and policies in healthcare coding and billing for ensuring compliance with rules and regulations • HCM-345-05: Evaluate the use of reimbursement data for its purpose in case and utilization management and healthcare quality improvement as well as its impact on pay for performance incentives 2 Prompt You are now a supervisor within the patient financial services (PFS) department of a healthcare system. It has been assigned to you to write a white paper.
You are now a supervisor within the patient financial services (PFS) department of a healthcare system. It has been assigned to you to write a white paper to educate other department managers about reimbursement. This includes how each specific department impacts reimbursement for services, which in turn impacts the healthcare organization as a whole. The healthcare system may include hospitals, clinics, long-term care facilities, and more. For now, your boss has asked you to develop a draft of this paper for the healthcare personnel only; in the future, there may be the potential to expand this for other facilities. In order to complete the white paper, you will need to choose a hospital. You can choose one that you are familiar with or create an imaginary one. Hospitals vary in size, location, and focus. Becker’s Hospital Review has an excellent list of things to know about the hospital industry. Once you have determined the hospital, you will need to think about the way a patient visit works at the hospital you chose so you can review the processes and departments involved. Conduct research through articles or get information from professional organizations. Below is an example of how to begin framing your analysis. A patient comes in through the emergency department. In this case, the patient would be triaged and seen in the emergency department. Think about what happens in an emergency area. The patient could be asked to change into a hospital gown (think about the costs of the gown and other supplies provided). If the patient is displaying signs of vomiting, plastic bags will be provided and possibly antinausea medication. Lab work and possibly x-rays would be done. The patient could be sent to surgery, sent home, or admitted as an inpatient. If he or she is admitted as an inpatient, meals will be provided and more tests will be ordered by the physician—again, more costs and charges for the patient bill. Throughout the course, you will be gathering additional information through your readings and supplemental materials to help you write your white paper. When drafting this white paper, bear in mind that portions of your audience may have no healthcare reimbursement experience, while others may have been given only a brief overview of reimbursement. The goal of this guide is to provide your readers with a thorough understanding of the importance of their departments and thus their impact on reimbursement. Be respectful of individual positions and give equal consideration to patient care and the business aspects of healthcare. Consider written communication skills, visual aids, and the feasibility to translate this written guide into verbal training. Specifically, the following critical elements must be addressed:
I. Reimbursement and the Revenue Cycle
A. Describe what reimbursement means to a healthcare organization. What would happen if services were provided to patients but no payments were received for these services?
B. Illustrate the flow of the patient through the cycle from the initial point of contact through the care and ending at the point where the payment is collected. Also identify the departments in order of importance to the revenue cycle. 3
II. Departmental Impact on Reimbursement
A. Many different departments utilize reimbursement data in a healthcare organization. It is crucial the healthcare organization monitors this data.What impact could the healthcare organization face if this data were not monitored? Describe why collecting data is required for pay-forperformance incentives.
B. Describe the activities within each department for how they may impact reimbursement. What specific data would you review in the reimbursement area to know whether changes were necessary?
C. Identify the responsible department for ensuring compliance with billing and coding policies. How does this affect the department’s impact on reimbursement in a healthcare organization?
III. Billing and Reimbursement
A. Analyze how third-party policies would be used when developing billing guidelines for patient financial services (PFS) personnel and administration when determining the payer mix for maximum reimbursement. How do third-party policies impact the payer mix for maximum reimbursement?
B. Organize the key areas of review in order of importance for timeliness and maximization of reimbursement from third-party payers. Explain your rationale on the order.
C. Describe a way to structure your follow-up staff in terms of effectiveness. How can you ensure that this structure will be effective?
D. Develop a plan for periodic review of procedures to ensure compliance. Include explicit steps for this plan and the feasibility of enacting this plan within this organization.
IV. Marketing and Reimbursement
A. Explain how new managed care contracts impact reimbursement for the healthcare organization. Support your explanation with concrete evidence or research.
B. Discuss the resources needed to ensure billing and coding compliance with regulations.
C. Evaluate strategies to ensure stakeholders involved in the reimbursement process adhere to ethical standards. Milestones Milestone One: Draft of Reimbursement and the Revenue Cycle In Module Three, you will submit a draft of Sections I and II of the final project (Reimbursement and the Revenue Cycle, and Departmental Impact on Reimbursement). This milestone will be graded with the Milestone One Rubric.
Milestone Two: Draft of Billing, Marketing, and Reimbursement In Module Five, you will submit a draft of Sections III and IV of the final project (Billing and Reimbursement, and Marketing and Reimbursement). This milestone will be graded with the Milestone Two Rubric.
Final Project Submission: White Paper In Module Seven, you will submit your entire white paper. It should be a complete, polished artifact containing all of the critical elements of the final product. Guidelines for Submission:
This white paper should include a table of contents and sections that can be easily separated for each department area.
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Maximizing Healthcare Reimbursement; Understanding the Revenue Cycle and
Departmental Impact
Lisa Calvo
SNHU
Mrs. Clemons
Health Care Reimbursement.
July 15, 2023
2
Maximizing Healthcare Reimbursement; Understanding the Revenue Cycle and
Departmental Impact
Introduction
In today’s healthcare landscape, understanding and optimizing reimbursement is vital for
the financial sustainability of healthcare establishments. Healthcare organizations are driven by
reimbursement financial operations, and respective section plays a crucial part in the revenue
cycle. This white paper aims to outline the necessary healthcare reimbursement knowledge by
examining the impact of reimbursement on healthcare organizations and the importance of
departmental compliance and data collection (Lin et al., 2020). This paper seeks to enhance
reimbursement efficiency and maximize financial outcomes by analyzing the revenue cycle and
identifying departmental responsibilities.
Section I: Reimbursement and the Revenue Cycle
Reimbursement is the backbone of medical services associations, giving the essential
assets to convey quality care to patients. It encompasses the financial transactions between
healthcare providers and payers, ensuring the services are appropriately compensated (Lin et al.,
2020). Generally, reimbursement refers to the pay received by medical service associations for
the administrations delivered to patients, either from private protection, taxpayer-supported
initiatives like Medicaid and Medicare, or directly from patients.
Assuming administrations were given to patients, however, no payments were received,
healthcare organizations would face significant financial challenges. Lack of payment would
strain the organization’s resources, obstructing its capacity to provide adequate care, put
resources into important hardware, and hold talented medical services experts (Lin et al., 2020).
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Moreover, failure to receive payments would prompt income issues, obstructing the association’s
capacity to meet its financial obligations and maintain smooth operations.
The revenue cycle illustrates a patient’s journey from the initial point of contact through
the provision of care, culminating in payment collection. It involves several key steps, including
scheduling appointments, verifying insurance coverage, providing care, documenting services,
generating claims, and processing payments (Abràmoff et al., 2022). Accurate and timely
information must be captured at each stage to ensure appropriate reimbursement and financial
sustainability.
Section II: Departmental Impact on Reimbursement
Monitoring reimbursement data within a healthcare organization is crucial for several
reasons. Firstly, it allows organizations to identify potential issues or discrepancies that could
lead to claim denials or delayed payments. By promptly addressing such issues, organizations
can mitigate financial losses and streamline the reimbursement process (Wei et al., 2023). Failure
to monitor reimbursement data could consequence in increased delayed payments, denials, and
revenue leakage, eventually affecting the organization’s financial stability and quality care
providing abilities.
Data collection is essential for pay-for-performance inducements as it permits measuring
and reporting quality outcomes. Quality metrics are significant in reimbursement models for
Medicaid Managed Care, Medicare, and commercial plans (Wei et al., 2023). By collecting and
analyzing patient outcomes and quality indicators, healthcare organizations can demonstrate their
performance and qualify for financial incentives tied to pay-for-performance programs. This
data-driven approach encourages continuous improvement in patient care and promotes
accountability.
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Respective department in a healthcare association can affect reimbursement in several
ways. For instance, the registration department ensures accurate and complete patient
information, including insurance details, directly affecting the billing and reimbursement process
(Abràmoff et al., 2022). The coding and documentation department ensures that medical records
are appropriately coded, reflecting the services provided. Any errors or omissions in coding can
lead to claim denials or reduced reimbursement. The billing department submits claims to payers,
ensuring proper coding, accurate charge capture, and adherence to regulatory guidelines. The
finance department monitors financial transactions, analyzes revenue trends, and oversees the
organization’s financial health.
In the reimbursement area Specific data need to be reviewed in the to determine if
variations are necessary. This includes tracking claim denial rates, average reimbursement per
service, billing and coding accuracy rates, and revenue cycle key performance indicators (KPIs)
such as days in accounts receivable and clean claim rates (Wei et al., 2023). Analyzing this data
provides insights into potential areas for improvement, allowing organizations to implement
changes that optimize reimbursement processes and financial outcomes.
The accountable department for ensuring agreement with coding and billing policies is
typically the coding and documentation section. They are crucial in accurately translating
healthcare services into standardized codes, ensuring proper reimbursement and compliance with
coding guidelines. Compliance with coding and billing policies affects the department’s effect on
reimbursement by minimizing claim denials, maximizing reimbursement rates, and reducing the
risk of audits or penalties associated with non-compliance.
Hospitals have leveraged Pay-for-Performance (P4P), Medicaid Managed Care,
Medicare, and commercial plans to drive quality outcomes in the digital and insurance-covered
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era. Hospital A implemented a robust electronic health record (EHR) system integrated with their
billing and coding software (Abràmoff et al., 2022). This allowed them to collect and analyze
patient data, track quality metrics, and report outcomes for P4P incentives. They also
collaborated with insurance providers to ensure seamless claims processing and reimbursement.
Hospital B focused on patient engagement through telehealth services, providing convenient and
accessible care while monitoring patient outcomes. They utilized data analytics to identify areas
for improvement and implemented targeted interventions to enhance quality. Both hospitals
embraced technological advancements and utilized insurance partnerships to optimize
reimbursement and achieve quality outcomes in this digital and insurance-covered era.
Conclusion
In conclusion, reimbursement is integral to the financial sustainability of healthcare
organizations, and understanding the revenue cycle and departmental impact is essential for
maximizing reimbursement. Financial challenges arises when there is failure in data
reimbursement monitoring, while proper data collection is needed for pay-for-performance
inducements. Each department within a healthcare organization contributes to reimbursement
through its activities, and specific data should be reviewed to identify areas for improvement.
Ensuring agreement with coding and billing policies is crucial for maximizing reimbursement
and minimizing financial risks. By embracing efficient reimbursement practices, healthcare
establishments can enhance financial outcomes and provide their parents with quality care.
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References
Abràmoff, M. D., Roehrenbeck, C., Trujillo, S., Goldstein, J., Graves, A. S., Repka, M. X., &
Silva III, E. Z. (2022). A reimbursement framework for artificial intelligence in
healthcare. NPJ digital medicine, 5(1), 72.
Lin, J. C., Kavousi, Y., Sullivan, B., & Stevens, C. (2020). Analysis of outpatient telemedicine
reimbursement in an integrated healthcare system. Annals of vascular surgery, 65, 100106.
Wei, D., Wang, Y., & Zhai, Y. (2023). The Impact of Reimbursement Policy on the Competition
between Public and Private Hospitals: Fee-for-Service vs. Bundled Payment.
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Draft of Billing, Marketing, and Reimbursement
Lisa Calvo
SNHU
Mrs. Clemson
Healthcare Reimbursement
July 30, 2023
2
Draft of Billing, Marketing, and Reimbursement
Third-Party Policies in Billing Guidelines
Developing billing guidelines that align with third-party policies is crucial for the success
of patient financial services (PFS) personnel and administration in healthcare organizations.
When determining the payer mix for maximum reimbursement, PFS personnel needs to
thoroughly analyze these policies and negotiate contracts with different payers to secure
favorable reimbursement rates and coverage criteria (Chen et al., 2021). In addition,
understanding the reimbursement rates and guidelines of various payers enables healthcare
organizations to strategize their services effectively, targeting payers that offer higher
reimbursements while managing patient populations efficiently. Healthcare organizations can
maximize revenue and financial sustainability by optimizing the payer mix.
Key Areas of Review
To ensure timeliness and maximization of reimbursement from third-party payers,
healthcare organizations need to prioritize key areas of review. First, submitting clean claims is
essential. Accurate and complete claims submission reduces the likelihood of claim denials and
delays in reimbursement processing. Second, pre-authorization and eligibility verification are
critical as they help prevent claim rejections and minimize payment delays. Third, Proper
medical coding and comprehensive documentation are vital for accurate claim processing and
reimbursement, making them key review areas. Efficiently managing claim denials and appeals
is also crucial to securing rightful reimbursements. In addition, timely payment posting and
reconciliation contribute to accurate revenue tracking and financial management. Adhering to
payer contracts and fee schedules is also important for fair reimbursement. Finally, persistent
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follow-up on unpaid claims and patient balances leads to better cash flow and financial stability
for the healthcare organization.
Structuring Follow-Up Staff
An effective structure for follow-up staff can significantly improve billing processes and
reimbursement outcomes. Healthcare organizations can achieve this by assigning responsibilities
to specialized teams within the follow-up staff. Each team can be responsible for specific payers
or tasks, such as denials, appeals, or patient collections. Moreover, specialization can enable staff
to develop expertise in handling particular aspects of the billing process, resulting in improved
efficiency and accuracy. Continuous training can keep staff updated on changing policies,
regulations, and industry best practices. Furthermore, performance metrics need to be established
to monitor staff productivity and identify areas for improvement (Sauermann, 2023). In addition,
open communication and collaboration among teams foster a supportive environment for sharing
insights and resolving challenges effectively. Integrating billing software and technology is also
crucial as it streamlines processes, enhances productivity, and enables staff to focus on valueadded tasks, leading to increased effectiveness.
Plan for Periodic Review of Procedures
A periodic review of procedures is essential to maintain compliance with billing
practices. Healthcare organizations can enact this plan by creating a comprehensive policy and
procedure manual outlining billing guidelines, payer policies, and compliance measures.
Furthermore, regular internal audits can be conducted to assess compliance with policies, coding
accuracy, and adherence to third-party payer regulations. External auditors can also be engaged
periodically to assess billing practices and compliance. Moreover, staff education is a critical
component of the plan, as it ensures that all team members are aware of compliance changes and
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reinforces the importance of adherence to established guidelines. In addition, the feasibility of
this plan relies on the organization’s commitment to compliance, allocation of resources for
audits and training, and integration of technology to streamline processes and support
compliance efforts.
Marketing and Reimbursement
Managed care contracts involve negotiations between healthcare providers and insurance
companies to establish service reimbursement rates and guidelines. Managed care contracts may
encompass negotiated payment rates different from previous agreements or the organization’s
standard charges. Insurance companies often seek to control costs, resulting in reduced
reimbursement rates, which can directly impact the organization’s revenue. Terms of managed
care contracts can also affect patient volume, as certain plans may become more or less attractive
to patients. This could lead to patient demographics and reimbursement mix changes, potentially
altering the organization’s financial stability. Moreover, managed care contracts often include
utilization management strategies and preauthorization requirements. Compliance with these
measures is crucial for reimbursement, as failure to adhere to them may result in claim denials
and reduced payments. Furthermore, several managed care contracts now incorporate quality
metrics and value-based reimbursement models. This shift focuses on rewarding providers based
on patient outcomes and cost-effectiveness.
Data from the Centers for Medicare and Medicaid Services (CMS) show that
approximately 73.4 million people were registered in Medicaid insurance on average in 2017, a
rise of 1.7% from 2016. Over the same period, adult enrollment grew by 9.0 %. These figures
demonstrate the importance of Medicaid as a payer source and highlight the significance of any
changes in managed care contracts about Medicaid programs.
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Resources for Billing and Coding Compliance
Compliance with billing and coding regulations is essential for healthcare organizations
to avoid legal and financial penalties and ensure accurate reimbursement. First, employing welltrained and certified billing and coding professionals is vital. These individuals need to be up-todate with the latest coding guidelines, such as ICD-10 and CPT, and be well-versed in applicable
reimbursement rules. Moreover, efficient Electronic Health Records (EHR) with integrated
billing and coding functionalities can streamline the documentation and billing. It can help
ensure accurate coding and claim submissions while reducing errors and denials. Continuous
education and training sessions for billing and coding staff are also necessary to stay updated on
changes in regulations and best practices. This can be done through workshops, webinars, or
professional conferences. In addition, regular internal audits can help identify potential
compliance issues and coding errors before claims are submitted. These audits can ensure that
billing practices adhere to regulations and ethical standards.
Strategies for Adherence to Ethical Standards
One of the strategies can be implementing a comprehensive code of conduct that outlines
ethical principles and expectations for all stakeholders, including healthcare providers, billing
and coding staff, administrators, and payers. Ensure that ethical behavior is also integrated into
organizational policies and procedures. Another strategy is regular training and education on
ethical practices and the consequences of unethical behavior (Benlahcene et al., 2022). Training
sessions need to emphasize the importance of integrity, honesty, and respect for all patients and
parties involved. Moreover, promoting transparent communication among stakeholders can
foster trust and prevent misunderstandings. Clear communication can help avoid billing errors or
intentional fraudulent activities. In addition, conducting regular audits and monitoring billing and
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coding processes can detect any irregularities or potential unethical practices. Implementing
checks and balances can ensure compliance and identify areas for improvement.
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References
Benlahcene, A., Saoula, O., Jaganathan, M., Ramdani, A., & AlQershi, N. A. (2022). The dark
side of leadership: How ineffective training and poor ethics education trigger unethical
behavior? Frontiers in Psychology, 13, 1063735.
Chen, P. G., Chan, E. W., Qureshi, N., Shelton, S., & Mulcahy, A. W. (2021). Medical device
supply chains.
Sauermann, J. (2023). Performance measures and worker productivity. IZA World of Labor.
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